Practising Clinical Reflection

Reflective practice is the process of retrospectively examining a certain procedure or experience and analysing it to determine whether things could have been done better. This now forms part of the undergraduate education in most medical fields due to its continuing value throughout practitioners’ careers.¹ It allows practitioners to evaluate their own level of skill and knowledge, and create ways to improve clinical outcomes. Reflective practice is also described as ‘critical and deliberate enquiry into professional practice in order to gain a deeper understanding of oneself, others, and the meaning that is shared among individuals. This can happen during practice or following a treatment, and can either be done alone or with others.’² 

Donald Schön’s 1983 book, The Reflective Practitioner: How Professionals Think in Action, not only focuses on reflection-in-action (how professionals reflect during practice), but also on reflection-on-action, when reflection takes place after the event.³ This book, in my opinion, is a cornerstone of reflection as part of professional practice. Reflective practice is extremely important as it looks at all the factors that may have contributed to decision-making. According to Professor David Seedhouse, we are more inconsistent than we think on a daily basis depending on our mood, how stressed we are, our level of knowledge and many other external factors.⁴ Looking at ourselves, our experiences and our values will help us understand how these relate to our treatment of patients and their clinical outcomes.^5,6 Reflective practice can be especially key in aesthetics, when you’re not working in your core medical field anymore. 

Reflective pathways 

Reflective writing is a way of processing one’s practice-based experience to produce learning. It integrates theory and practice while identifying a learning outcome from an experience.⁷ As such, it is a powerful tool for self-development in any field, and has become a mainstay within the medical field to promote an ethos of continuous development and self-awareness.⁸ Reflection itself is a type of self-regulated learning which incorporates cognition, metacognition and motivation.⁹ 

Cognition is the mental process of knowing, understanding and learning, while metacognition is the conscious planning, monitoring and evaluation of one’s own learning. As such, motivation to undergo metacognition can lead to cognition. In order to wrestle these abstract concepts into workable action plans, several authors have created reflection models in order to provide more defined processes and endpoints and I believe all of these can be applied to aesthetic practice. 

Sociologist and psychologist Graham Gibbs’ created the Reflective Framework, which is commonly taught to clinicians, and prompts us to consider what happened and how we felt at the time of an event, what the good and bad points were during the experience and what alternative actions could have been taken.¹⁰ This then leads to the formulation of an action plan when encountering similar situations in the future. An alternative framework is presented by American educational theorist David Kolb, in which he stipulates that learning ‘is the process whereby knowledge is created through the transformation of experience’.¹¹ Kolb suggests that for this transformation to occur, an individual must progress through a four-stage cycle. 

The key skills for reflective practice include the ability to:¹² 

• Problem solve 
• Build on existing knowledge 
• Explore questions in depth 
• Be critically aware 
• Be open-minded 
• Motivate themselves 
• Be self-aware 
• Recall 
• Use theoretical perspectives appropriately 
• Gather information and critically evaluate it 
• Learn from experience 
• Create personal knowledge 
• Question professional assumption, values and beliefs

Putting it into practice

When reflecting on the many aesthetic non-surgical treatments I have provided over the years, many factors come into play and need to be assessed before any treatments are undertaken. These are summarised in the Interconnected Circle which I created over time and share with my students. I would go so far as to say that any aesthetic treatment, including the use of botulinum toxin and dermal filler, should not be carried out until we have an understanding of all the aspects of the circle. This will enable us to question any professional assumptions and beliefs regarding the provision of treatments. By reflecting in this way, we can continually learn from both the positive and negative outcomes of treatments. 

The Interconnected Circle 

The Interconnected Circle helps me not only with treatment planning, but also with reflection. For example, the Anatomy/ Ageing Anatomy subheading highlights the importance of the aesthetic practitioner having a sound understanding of anatomy. A practitioner trained in functional anatomy is better set to create, alter and/or reconstruct to achieve aesthetic success. Understanding the anatomy enables us to more accurately reflect on the treatments provided. In my mind, the consultation is the most important aspect of a patient’s journey, as the practitioner may identify:¹³

• Poor rapport 
• Unrealistic expectations 
• Minor or non-existent defect (a potential sign of body dysmorphic disorder) 
• Attitude of perfectionism 
• Vagueness (unable to describe wishes) 
• Impulsiveness • Previous unsatisfactory surgery 
• Litigation against other doctors 
• Emotional crisis (such as death in the family, divorce, loss of job) 
• Demanding personality 
• Demeaning of others, especially your staff 
• Disapproval by family for the surgery 

Case study 

In this case study, reflection played an important role in determining the reason for an undesired treatment outcome of one of my patients. A female patient in her late 40s was treated for upper and lower lip augmentation with non-permanent dermal fillers. Immediately after the treatment, the patient expressed her satisfaction with the results of the treatment and no adverse events were noted, i.e. no obvious bruising or abnormal swelling. The patient was given post-treatment instructions both verbal and written, and was discharged. 

Approximately five days later, the patient contacted me by email, with photographs which showed severe bruising on both upper and lower lips. On contacting the patient, it was elucidated that there was no pain or infection. The patient was reassured and advised to continue to follow the post-treatment instructions, which included application of cold packs. The patient was contacted regularly for follow-up, and after approximately 10 days the bruising, had greatly reduced and any residual bruising could be concealed with the use of makeup. On the next follow-up appointment with the patient two weeks later, the bruising had completely subsided. 

Why had severe bruising occurred? My first evaluation was to determine whether it was the patient, the practitioner (myself!) or both. Using the Interconnected Circle as my template, I determined that there were no factors associated with the patient which could have contributed to this severe bruising. The finger was then pointed at me! On reflection, the following factors were deemed to be potential, singular or multiple, causes of this bruising, in that I: 

1. Injected too deeply 
2. Injected in the proximity of a major vessel 
3. Injected too quickly 
4. Injected too ‘vigorously’ 
5. Injected too much product 
6. Injected too viscous a product 

Start reflecting 

I find that using the Interconnected Circle as a reference point focuses my mind during the consultation to ensure provision of the ultimate patient outcomes. Additionally, when things don’t go as well as expected, or the outcomes are not as one would hope, I find the Interconnected Circle to be a useful tool to revert back to. I believe there are two main criteria regarding patients and aesthetic non-surgical interventions. The first occurs at the consultation – as previously, stated, I believe this is the most important aspect of any treatment modality – where we determine whether or not the patient is treatable. If not, they are politely shown the door. If we feel that they are treatable, the second criterion is to ‘avoid the unhappy patient’ and all that entails.¹⁵ 

Experience and reflection give us more understanding of these critical issues and amplify the value of reflection and how it can improve practitioners’ practice.